Provider Demographics
NPI:1366788168
Name:STROUD, SUSAN KAY (MED; EDS)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:STROUD
Suffix:
Gender:F
Credentials:MED; EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-3518
Mailing Address - Country:US
Mailing Address - Phone:360-678-4409
Mailing Address - Fax:360-678-0540
Practice Address - Street 1:501 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-3518
Practice Address - Country:US
Practice Address - Phone:360-678-4409
Practice Address - Fax:360-678-0540
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAESA-376284F101YS0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool